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I <br />a y <br />i <br />WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 <br />(Ed. 4-84) <br />WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA <br />We have the right to recover our payments from anyone liable for an injury covered by this policy. We will <br />not enforce our right against the person or organization named in the Schedule. (This agreement applies <br />only to the extent that you perform work under a written contract that requires you to obtain this <br />agreement from us.) <br />You must maintain pav-,ci! records ac;urately segregating the remuneration of your employees while <br />engaged in the work described in the Schedule. <br />The additional premium for this endorsement shall be 2 % of the California workers' compensation <br />premium otherwise due on such remuneration. <br />Schedule <br />Person or Organization Job Oescript:ion <br />J <br />ANY PERSON OR ORGANIZATION FOR WHOM / ALL JOBS IN California <br />THE NAMED INSURED HAS AGREED BY <br />WRITTEN CONTRACT TO FURNISH THIS <br />WAIVER. <br />This policy is subject to a minimum charge of $250 for the issuance of waivers of subrogation <br />This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. <br />(The information below is required only when this endorsement is issued subsequent to preparation of the policy.) <br />This endorsement, effective 11/10/2015 <br />Policy No. EIG 1400371 04 -"" <br />at 12:01 AM standard time, forms a part of <br />Of the EMPLOYERS PREFERRED INS. CO. <br />Carrier Code 00920 <br />Issued to TRB AND ASSOCIATES Endorsement No. <br />Premium <br />Countersigned at on By: t/ <br />Authorized Representative <br />WC 04 03 06 <br />(Ed. 4-84) 01998 by the Workers' Cornoensation Insurance Rating Bureau of California. All rights reserved. <br />